You have the right
to be informed about the recommended treatment plan so
that you may make an educated decision as to whether or not to undergo this
procedure. This disclosure is not meant to alarm you, but is an effort to provide
information so that you may give or withhold your consent.
Dental Implants have been around
for many years, but the success has become
more predictable since the use of the pure titanium cylindrical osseointegrated implant.
I understand that the purpose of the dental implant is to provide support for dental
prosthetic reconstruction in the form of a single tooth, bridge, or denture, or to provide
orthodontic anchorage.The purpose of dental implant(s) is to provide stability, support
and/or retention for a crown, fixed bridge, fixed denture or removable denture in the
absence of natural teeth.
The first procedure
involves drilling small holes into the jawbone and placing the
anchors. Depending on the condition of the mouth, bone grafting or guided tissue
regeneration also may be necessary to install the implants. If you need extensive bone
grafting, your implant procedure may be done at a later date once the bone is built up
properly so that it can accommodate an implant.
grafting can be done at the same time of your implant surgery.
The Dentist will determine your specific case.
At times, the course of
treatment can be altered depending upon the clinical
situation of the area. Sometimes the Dentist will place implants right away; however,
when the Dentist opens up the surgical site, there may be cases where the clinician
finds it in the patient’s best interest to change the planned procedure from the original
planned treatment. It is possible that he may just place bone graft at the 1st surgery
instead of the implants and change his plan based on his clinical judgement.
You will be given an anesthetic
to numb the pain. You may also be put on
antibiotics and be given pain medication if needed. A temporary denture or flipper may
be worn for a few months while the anchors bond with the jawbone and the gums and
bone heal. At the end of the surgery, depending upon the condition of the bone and
gum, the dentist will either seal the implant with a cover screw and bury it in the gum or
a healing abutment will be placed on the implant to form the gum tissue around the
implant. Both techniques will protect the implant during healing, but the Dentist will
decide which method is best for your case.
After 3-6 months following the implant surgery, The patient will come back to test the
implant area(s). During this visit, the Dentist will test and torque the implants to see if
the implants are ready to be restored with the implant crowns, bridge or implant
integrated denture. If the implant was buried, he will make a small incision and remove
the cover screw, placing a healing abutment. The patient will return 4-6 weeks later to
take impressions or scans for the final prosthesis.If the implant is unburied and just
covered with a healing abutment, the healing abutment will be removed and the implant
tested by torquing it. An impression or scan will be taken of the area and sent to the lab
to fabricate the prosthesis. Fabrication of an implant prosthesis will be designed by the
laboratory based on the Dentist’s measurements and approval . The final insertion will
take place about 2 weeks later.
we cannot predict the length of time dental implants will provide
service in the oral cavity, nor can we guarantee if this procedure will succeed. I know
that smoking lowers the chances of implant success in direct proportion to the amount
smoked. I also understand the risks involved in this procedure. I understand that the
implant surgery and prosthetics will be done in the established way and that the risks in
the front of the mouth consist of the usual ones associated with simple gum surgery
including, but not limited to:
- Post-operative pain and discomfort, swelling and bruising
- Infection that may require further treatment. and bleeding.
- Injury or damage to adjacent fillings or teeth
- Restricted mouth opening during healing sometimes related to swelling or
- Other complications may include trauma to the nerve tissue or blood vessels
that may lead to loss of /or an altered sensation of the tongue, cheeks, gums,
chin, lip or other tissues in the mouth specifically on the treated side in the lower
jaw, and the creation of a communication between the sinus and the mouth on
the treated side in the upper jaw (opening of the sinus). Such risks can also
include a chance of fracture to the bone or jaw. These complications would
require further surgery for correction.
- Poor bone quality, requiring either no implants to be placed or proceed with
surgery with a lesser rate of success, possible grafting.
It has been explained that in some instances implant(s) fail and must be removed.I
understand that in the event the implant fails to integrate, it must be removed through a
second surgical procedure, and there can be no refund of all or part of the fee for the
lost implant. I have been informed and understand that the practice of dentistry is not
an exact science; therefore, I understand there are no guarantees or assurances as to
the outcome of treatment results. I acknowledge that there is a chance that the
implant(s) placed can fail and I am taking a risk by agreeing to this surgical procedure.
To my knowledge,
I have given an accurate report of my physical and mental
health history. I understand that excessive smoking, alcohol, or blood sugar may
affect gum healing and may limit the success of the implant(s) and restoration. I
will report any significant change in my health should it occur.
Excessive forces, as grinding or clenching my teeth, on the implant(s) may lead to
loosening and/or fracture of the retaining screws or cement; fracture of the porcelain,
metal or acrylic on the prosthesis; loosening and/or fracture of the implant(s); and/or
loss of bone around the implant(s). Any of these may cause loss of this implant(s).
Additional treatment and associated costs will be involved should this occur, including,
but not limited to occlusal guards.
The possible risks and complications for fixed prostheses include:
- compromised appearance and/or lack of support of the lip(s) and cheek(s) as a
result of inadequate bone
- air escaping underneath the prosthesis while talking which may adversely affect
speech and/or food entrapment underneath the prosthesis since space is
necessary for homecare of the implant(s).
- sore gums, food entrapment, wearing of attachments, replacement of
attachment components, and initial problems with speech.
The potential benefits of this
procedure include the replacement of missing
natural teeth or supporting dentures.
Alternatives to this treatment
have been explained. I understand the alternative
conventional dental treatment options and I am aware of the consequences of receiving
no treatment. I desire an implant prosthesis to help secure the replacement of my
missing teeth. The entire procedure has been fully explained, including the benefits
and possible risks. I have been given the opportunity to ask questions regarding the
procedure and they have been answered to my satisfaction. I have not asked for, nor
have I received from anyone, a guarantee of the outcome of this procedure.
It has been explained
to me that once implants are inserted or implanted, a
recommended program of personal oral hygiene must be strictly followed by me
and completed on schedule. I have been informed that if this schedule and plan
are not carried out, the implants may fail.
I agree to make every effort
to return for follow-up visits for hygiene and exams
after the surgery in order to have any necessary x-rays taken but I am aware that this is
entirely voluntary on my part. Follow-up care for the implants and prosthesis is
extremely important to the success of the implants or Bone graft. It will be necessary to
return to the office at regular intervals for examination and service. Keeping your gums
and teeth healthy by coming for hygiene visits every 3-4 months is one of the best
ways to take care of your implants. It has been made clear that failure on my part to
keep my mouth, implant(s) and prosthesis thoroughly clean may jeopardize the
success of my implant(s). I realize that unforeseen long term factors may necessitate
additional surgery, modification of the implant(s) or even surgical removal of the
implant(s). I also understand that I will be financially responsible for long term
maintenance and/or any modifications required, including but not limited to cleanings,
attachment replacements, x rays, and examinations.
Photographs and clinical data might be used in scientific papers and
presentations and the confidentiality of the patient will be respected.
I consent to the administration of anesthesia or other medications before, during
or after the procedure by qualified personnel.
There is a chance that during the course of the treatment unforeseen conditions
may be revealed that may require changes in the procedure noted above.I
authorize the Dentist to use professional judgement to perform such additional
procedures that are necessary and desirable to complete my surgery.
I certify that I have read or had read to me the contents of this form. I will follow
any patient instructions related to this procedure. I confirm that the proposed
treatment and potential risks and/or complications associated with the procedure
have been explained to me. I understand the potential risks, complications and
side effects involved with any dental treatment or procedure and have decided to
proceed with this procedure after considering the possibility of both known and
unknown risks, complications, side effects and alternatives to the procedure. I
declare that I have had the opportunity to ask questions and all of my questions
have been answered to my satisfaction.